Chronic Oedema Study Day - 1

Chronic Oedema Study DayAims & Objectives
• Understand the aetiology of oedema • Able to identify types of chronic oedema • Understand disease progression • Conducting Holistic Assessment • Identify management options • Explore your own attitudes to chronic oedema
and how these may influence your care
Practical Sessions
• Managing toe oedema – Toe caps – Toe bandaging – Stump bandaging
Take 5 -
You arrive at work and find on the list of patients you’re seeing today a patient described as having large, wet, leaky legs. How do you feel about this forthcoming appointment?
Oedema
“Oedema is the presence of palpable swelling resulting from increased interstitial
fluid in the tissues.” BMJ 2009
Acute oedema
• Associated with strains & sprains – inflammatory
response leads to increased permeability of vessels
• Venous reflux & standing / sitting for long periods
• Without treatment it may become chronic
Acute oedema Pitting oedemaAnkle & feet swelling
Chronic oedema • Chronic oedema is an umbrella term for abnormal
swelling of the leg, caused by an increase in fluid in the tissue;
- that’s been present for at least 3 months - is not relieved by elevation or diuretics
• Most commonly due to problems with the venous and lymphatic systems
• Associated with skin & tissue changes
• Tendency to bacterial & fungal infections
Incidence • 100,000 people suffer from chronic oedema at any time (UK)
• 5.4 per 1000 in those over 65 years
• 10.3 per 1000 in those over 85 years
• Equates to 1.33 per 1000 population (Moffatt 2006)
However, Lymphoedema is not recognised by many practitioners (Logan 1999, Sitzia et al 1998) & these may be underestimated figures .
The Circulation Systems • Arteries - deliver oxygen &
nutrient rich blood around the body
• They branch into tiny capillaries just one cell thick
• fluid containing nutrients & oxygen filter out into the tissue spaces – interstitial fluid
• Cells in the tissue spaces absorb these and excrete waste and CO2
• Some filters back into venous system, larger molecules into lymphatics
• This maintains fluid balance in a normal limb
The Venous System
• For blood to be effectively taken against gravity back to the heart the body needs valves in the veins to prevent the backflow of blood
• Calf muscle pump assists venous return
The Venous System
When the deep system has faulty valves (the valves do not close tightly allowing the blood to leak back down) changes can start to occur within the legs. This is known as venous insufficiency and results in venous hypertension.
The Lymphatic System
• A one way drainage system that returns fluid to the vascular system via a network of lymphatic vessels and lymph nodes.
• It comprises of a deep and a superficial system of vessels
• The initial lymphatics are slightly larger than capillaries
• They absorb excess water & waste products, especially protein & fat, which are too large to enter the venules
• 90% of the interstitial fluid returns into the blood circulation via the venules
• 10% returns into the lymphatic system
Oedema
• Caused by an imbalance of the equilibrium between the
hydrostatic forces that push fluid into the tissue spaces and the
osmotic gradient that draws fluid into the intravascular space.
• If the balance of these mechanisms become overwhelmed or
obstructed, fluid accumulation becomes evident as oedema.
Fluid Balance
lymphoedema
Lipoedema
Lympho-venous oedema Venous hypertension leads to increased fluid in the tissue spaces. Over time leads to lymphatic overload and damage Causes: • DVT/post thrombotic syndrome • Severe varicose veins • Phlebitis • Trauma (eg damage to veins) • Chronic venous insufficiency • Obesity • Immobility
Lymphoedema
due to a failure of the lymph
drainage system to remove the
protein rich interstitial fluid.
Primary Lymphoedema – congenital deficiencies
Secondary Lymphoedema e.g. as a result of damage to the lymphatics:
Radiotherapy Surgery – orthopedic, removal of lymph nodes Extensive burns Tumour blockage Infection – Filariasis, cellulitis, insect bites Inflamatory conditions eg rheumatoid arthritis,
dermatitis, eczema Skin grafts Venous disease
Lipoedema • An inherited condition - occurs almost
exclusively in women
• Gradually develop during puberty.
• Abnormal distribution of fat cells in the lower limbs – unknown aetiology
• Bi-lateral
• Feet & toes generally unaffected, Typical ‘bracelet effect’ – negative stemmer sign
• Lipo-lymphoedema may develop due to long term impact on lymphatics
Disease Progression
• If left untreated chronic venous and lympho- venous disease will progress along a continuum of increased swelling and chronic inflammatory skin changes
• It is essential that early venous and lympho- venous disease is recognised and appropriate treatment is initiated to slow and control it’s progression (John Timmons, Janice Bianchi Wounds UK, 2008, Vol. 4, No 3)
Signs & Symptoms
• The fluid, red cells and protein present in the oedema cause certain skin changes
• Around 94% of people with venous & lympho- venous disease experience skin changes (Herrick et al, 2002)
• These skin changes produce signs and symptoms that help us to identify people at risk or suffering with chronic oedema, its severity and the level of intervention required
The Early Stages
Spider or thread veins Web of fine superficial veins just visible through the skin
Bulging veins May only be visible when the patient is standing
Ankle flare Distension of the small veins on the medial aspect of the foot
Mild oedema with aching legs Relieved overnight
Mild/moderate varicose veins
Venous dermatitis Also called varicose eczema. Itching caused by stagnant blood components leaked into the interstitial spaces
Hemosiderin staining Brownish red skin discolouration caused by
hemosiderin (red cell) deposits under the skin
Mid-term disease Atrophy blanche Painful absence of pigmentation caused by damage to microcirculation in the gaiter area
Severe varicose veins Chronic oedema – The presence of oedema at any stage, if left unmanaged can accelerate disease progression Ulceration 70% are venous
Hyperkeratosis Increased thickening of the stratum corneum
Chronic Disease Enhanced skin folds Swollen limbs become over stretched and in severe cases the skin forms hanging folds
Papillomatosis papules or nodules protrude from the skin giving a cobblestone appearance
Lymphorrhoea – ‘wet legs’ Protein rich fluid leaking from the superficial lymphatic system
Lipodermatosclerosis Fibrin deposits cause prolonged inflammation resulting in induration around the ankle area giving a woody feel. In severe cases a ‘champagne bottle’ shape
Cellulitis
Lymphangiomas Dilated lymphatic capillaries in the dermis which look like small blisters
Compression Therapy
Compression therapy can help to improve skin integrity, restore the limb to a normal shape,
and enhance the patient’s quality of life (Osbourne, 2009)
Can be safely used on patients with an ABPI ≥ 0.8 to 1.2
Compression • Hosiery
• Bandaging – to decongest the limb prior to
moving to maintenance with hosiery
– With ulceration/lymphorrhoea – Distorted limb shape
maintaining limb volume reduction than hosiery
alone” (Badger et al 2000)
• Inelastic multi-layer bandages for oedema
reduction
Inelastic bandages effects
• Increased lymphatic re-absorption and stimulation of lymphatic transport
• Improved venous pump in patients with venous- lymphatic dysfunction
• Breakdown of fibro-sclerotic tissue (EWMA 2005)
Before
Before After
• Untreated cardiac failure – start slowly one limb at a time
• Acute deep venous thrombosis – commence once comfortable and anticoagulation is stable
• Superior vena cava obstruction
• Advanced small vessel disease
Presenter
Presentation Notes
Show the Chronic oedema bandaging video 1st Demonstrate shaping leg and 8,10,12 cm actico bandaging Split into pairs to bandage one leg each – keep the bandages on at the end and then demonstrate stump bandaging Then move onto toe garment slides and video of toe bandaging LUNCH
Toes 1) Stump bandaging – for weeping or very
deformed toes
• Off the peg – measure circumference at ball of foot
• Use under bandages • Trim to fit – seams on outside
Toe Bandaging Please watch the following
video If you think this is appropriate
for your patient please contact Tissue Viability & we
will assess, and access training for you.
Chronic Oedema Study Day - 1
Aims & Objectives
Practical Sessions
Take 5 -
Before After